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A27 248Oct'-09-OZ 11:18A • , � �� ' /��7 �� . Aoaiit�tti� r�: i b'o�-6 � � 2� G`i� 3 Tax Man �: d� / �� b � �� - o��`� � Qarcai �: % � ��;'�� .� �� C � �T1�i''�`` �" s��„��.,--- ��..,5da �roda��. � • . << : �:� � P.Ol lF TH� INFOt�}IIIAI'tON IN THE APW:.�CLATIQN FOR AN 1141E'RQ�L�iMEN'l" F�2MTT iS 1NCQRRE�T F IFiE�J� CHA1�iGED, aR TH� 3tT'E 15 ALTEREU. THElV TWE IM�ROVEIII�' PERlIAiT AND AUTHORI�ATION TO . CQNSTRUCC SHALl. B�C�II�E INVALlD. - ,, Pe�� b,,: co,�►�o��e �,: n� l� v r Home Phane: �� Address: � c 8usiness Phone: 5 C S.� 2� Name and �ddresa o# curtsrt! vwnar: � o (�0 . � , �� 5 . c. ,. ^n Ir� 3) Propw�/ Daacrtptlon: l,.at slze: J'r��D Towmshlp: d�%t i Subdlvlsitm• 0��'� Lot#� Dh'ec#kms to the pmAerlY (Induding rosd namas•and numbecs): •� 1 4) Propo..ci iJsa anSt3iruc�ture Deacrl�on: answ�er sac�1o� the fnii ng questions: / a) Propoaed t/ Extsttnng . Type of structure: IYl oNul w- (�bm � width: �+J b oeptf,:�_ b) Number ot Bedrooma: 3 Number a!' ocraapafrts or people to be served: .i c) Besesnent Yes_ No�, Wf11 there bQ plumbing In the-basement7 d) sarbe�e Dispossl: Yes _ . No �, 5) Wa�rar SuPPhI �IPe: Privaba „�..(n�w � exlsting�, Publlc_, Cammunliy� . Spcing . Are any wells on ac#joining property? Yas_ No � If yes, ple�se indtr.ate app�.vclmabe location o� tfie 'stte pl�n. � Daea your propsrty corrtain_pmvioualy tdentt}ted jur[sdlctlona! wetlatx3a? Ysa_ No�, .��li 1. � �lil ►. > A PLAT OE TNE PRaPEi2TY OR 3TTE PLAN MUS7 BE SUHMI'T'TED W!'TH iH15 AP�t1CATiON. ➢ PROPE3iTY LlNES AND CORNEt29 MUST' BE CLEARLY YARI�. •, � THE PROP08m LOCATION O� A1.L 3'7i�UCTURES NIL13T BE 3TAl�D OR Fl_AGGED. � THE 3(TE a1U$T BE READILY ACZESSiBL.E F'OR AN EYALUATION BY THE H�Ai.TH DEPARTMF�tI' 3TAFF. . I hereby maka appllc�tion to the Pe1so� Courtty Health �epartment fac a site evaluatIon for the on-siie sewage dfaposal system f4r the above-descrihed proQerty. 1 agree ti�at the c�ntentis cf thls application ara true and re�resent t�e maxtmum faciiltles t� be plsced on the prope�Y !,q�.nclerstand if the stbe is �itered or tha it�6anded use changes, t�e permii shall became invalid. _ / % /J - - /D-,�Ya3 Data PCND, fLw. OE3I271Q2 l�� " "�� V � ' .��4y1.�� ,�q ^ �y.r . . `i..I• V i�� 1i� 7�.s�v�i��--�-� ��m.�l. 7�7Z�.m��a. • S�. �� - � �� ...s - � • � ' '►■t..• Y�e � �� s_"1_� � � . .� .. � IO � ■ :.• Y.� L- `. � :w� T� -� # Aa� P�c�I # � � � Secti,on/Lot# � . (a��r� . . Da�e � . � Syst�s�t �osrs�onesa�s a�ia�seat:a�euate�r�+nrsrs �►. �''�ae �r a�rrat,�lag� �ae s�s�s�itr.�a� ta. � �� is ��rs #o �a tdu�t�r�e�-gsbade as �a�s�ied � rL— �n S��L-C�b� � `Widc� �J(�,��dccP . C,onF�rc>,-tce ' d P� c, hatcs t.�p _ iYl c�nda.�o� '}"C,or�u�a� �P ��ll �.)�qravcf� ita�d.P�Pc, r OLL�IG r5 �3 f�,o JC�S,, . j�.t� 15`minirnur+ SC'�x`C�C' -�� SY S�-r^ �� , � �'' � �� / i � . ;, % . �' I � � . ' � ;� . -� /^� � . C�� - Zab�� \��o., , �=i0�� Scal� � . � D _� � / �O q. �/' � 130' � 9s• f 110' L AS T LinG TO P JL \ Ed�� S r� �s- To Ssdc . ��, To L.'1c � <<nc ��3, xe�. fl9/32/'D1 ��. � �'1��.� �� --- � � �� (' 1E;�.��mm � ��.�. �L�L�.�.1,e1� Owner: /��mc, t"ica�f�a��s Tax Map: Aa � Parcel #: �� Date: �.� -� (-�3 �.ame Tap Ta� (Scl�) Tap �'low i.,ine ��g�a ��ow ! ��ot # D'aamet�r(�) ( in) �, (ft) a z 4c� � 1 90 .o� 2 ' 40 � 7� � 9 d . O l� 3 ' 40 7� I 8fl . 0 9 4 � L 4� 'I,i 0 .o� s �IL . 8o s.s �� . � 6 � S�S `1D . � � s --- 9 �9 0' 10 ��A ft of line x 65 gal. per 100 ft =�u� i aaD 3,�a0D ; 100 = 3�a' gal 75% x 31 a ga1= a� ga1 per dose 3`� i 9 gal per minute (gpm) = k'9ow �8ate �ricdon �ead � ,,,��,,,,� �.oss: ��.3 ft per 100 ft of supply line x �50 ft of supply.line = 100 =�Z' ��ft 1�.�� ft x 1.2 = S�9 S4 ft of friction head Manifold Siae: � "�+'orce Main Size: � " PVC �otal Dyn�nic �ead = 1 � ft of Elevation head +�_ft of Pressure head -+�+�s9 ft of Friction Head = j1% 9S9 TDH -f L'an�iSip6Dnk(c � Pump �equire�ent: � GPM @ � U . ft of Head �rawdown: oZ3 4�al per dose ; 21 gal per inch = �► � inch drawdown per dose � , . ;�: � �:� . � � �:�. :.:,: , ,. � a � �� - �t a��rs � � . , . . . . . . , , _., � � ,. ., �[t��o�oo " W II II II 1.•;:..N......°.•°I....•:...•....: -.... :.. . . ..._ ............................ = = � � ' - � :� �- �,►�. 7d.►rma� 9�� -p—� ifold 5iz� / � Niax No. Ta� uce �/: �or ans 3/r" Zn � � Z G P�► r a' �o N - 1 I `� �r��da�� I 1� ��C��Lf WEoS�k Goc,�.ld5 off one side �%r p in �othsides) ��A(Cn� cy� 16 y =' �r ¢p-t- 2 i 12 . . . _ � " Flow er Tap Si�e Llarerial r�niv G�?iI -_ " Sclied 80 �•� 1, „ ' Sctted 10 ".I ;, ,• .Scl:ed 30 !21 ;!, ,. �Ci1ec1 �9 L- � h / . •. '� ' -' ' .,. . � • . 1h,dergro�md Cable In Caaduit With S�i.table Sealer In 8och Fiids OE Cau�uic �i �.ir_ � • � •�• _ •• • - _� . - ..� ' . ■• - ■ •. t�� •• ��• . • - • • • •�c- � - -• •• .i . � �- .��i • • � '�I� '!� � �'=3 i ; ... _ �li__ . _ � — _.� , '� � _� Sui�nersible Sa+ege �� Ef fl�ent P�q �• 4" �6'�Cazcrete Block • car�i� ri�-• � • - '� -a a• a� F, .i ir«■ i[a _� • •��r• a� � • � r �i • •�r �- a i 2I37„S�1 CsI� � . � � ,��-�t,_,�l _r�, _ ,<< � _._. I11 = I�t = l�l = itl. �. ��I 1 ��= 1� 1=- t� �_ � l( =rll.�..-.,.--'''`':. . , , ; :,.-� : � � �� I�� ,Gallon Tantc . � � . � . ,� �� . � �.Supply Line 'Io .� __ � . Diare[er S�eduie 40 PVC ..a pi� • 1LT1 RIYp � � .. } J • Cs3CE' n�� • �1L83�� Up10�i • Q�edc aalve 3/16" Syp�n Br�� ale ' " r.oc�ar� st� � Au c� Ala=n, Ftca� (elevation) •'Pu� On" Fioat (elevation) • • ••Puop Off" Floac (elevation) �, � ,� PUMP RATING pnmp Hust Be Rated To Deliver „ �Z Gallons Per Hinute � Against Feet Of Tota � ' Dynamic i�ead (TDH) . � I � •. , . . . a a o • • • • d ' ' d, d • �. _ . p . a a , � • . � • • • • m,; ��tc� st�u be c� a st�ke ��p ��' �Sir�n �1 sall be Ia�lc �ter3. �i.t� . PUMP SYSTEM DETAIL SHEET � See Following Sheet For Additioaa2 Specifications, Noces, And Explanations. 0 ��.) f �� ..� �- C� � �� I��daa-��.,.-„-„ ��.]L IHL��.IL�I� Applicant: �1 � Mc, i�cli.c� c,�.�-r�C�S Location: / SE� I,J 1Z. 7"�tin lJ ��nbtc�. T��x M�a�� - P�rc�i # � � • i S�uhelivi�:��ion � Pha�se Sect�ion Lot ? � Improvement Permit Permit Valid for � Five Years _ No Egpiration Type of Facility: � ti nr ( c. �in� i t Y � l,�.i C.< < i n-9. New �Addition Water Supply ri �`ft-Wc-I( # of Occupants �� # of Bedrooms 3 Projected Daily Flow loa g.p.d. Proposed Wastewater System: Co C/ti '�nG-f . Type: �� Proposed Repair: �l�►�n �i��'1 D va�7�V c. (a�yo R.Cof�.eG-EI'on Type: l�'� G Pernut Conditions: Owner or Legal Represe Authorized State Agent: S -�c,�r a..s F�� 9 y� d� cc �c� �,cd r�d � rc� Date: Date: /a -I 1-c73 The issuance of this permit by Iiealth Department in does not guarantee the issuance of other permits. It is the responsibility of the applicandproperty owner to in s e that all Person County Planning and Zoning and Building Inspections requirements are me� This Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement Permit is not affected by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina Zaws and Rules for Sewage Treatment and Disposal Svstems' (15A NCAC 18A .1900). Neither Person County nor the Environmental Health Specialist warrants that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain potable. Autho.rization to Construct Wastewater. System (Required for Building Permit) * See site plan and additional attachments (�___). Propos•e� Wastewater System:�(,tm p� Ut-/� {,'l a^u� ( Type�� Wastewater Flow3�O� g.p.d. New Y Repair Expansion Soil LTAR: • a� g.p.d./ ft 2 Type of Facility: �� Ic. Fcun i lY OWc,(1 inq Basement Yes No Wastewater System. Requirements Size: Septic Tank: � gal Pump Tank: I,OOC7 gal Grease Trap: iJ! i� ga1 field: Tota1 Area: �a sq ft Total Length 9 W ft Mazimum Trench Depth �. in �h Width 3 ft Minimum Soil Cover: � in Minimum Trench Sepazation: � ft ibution: Distribution Box Serial Distribution V Pressure Manifold Tn�St�,(1 di�zrsr'� d�t�► �,s S�own �.(r�,in{�i� �S'mintimu�-E� Scpt�c., (�Ou-[ci Q�d !�a o`� � 3'' n F 5 � i I O J�l S v�S i�Crr� �o r' �dc%'a�a ( CAt1� � Authorized State Agent: Perinit Exx The type of system permittec the permit. Owner/Legal Representative: Date: )a-II-O-'S �n Date: � � -1( -O$ � is �% Conventional Innovative Alternative. I accept the specifications of Date: PCHD7/30/2002 � d . : ;:y . 0 � � �� . ��. � �1j�� _ �� T � � -0�� ZE�.-Q.��.�.��.�.g �3C��.1L��. iicar� ��- � `� � � ..�,�.....: ., , r,n . J � � �� I��I �� / CiII L.Ci , 1�L.1:� �I � ` „I.L.I I � I �I�,;��:= ,�i�?'�r,r� i-- . � , . :C��3� �r�t� 0 i"� ' P� ��'1�$ . � � ' • ... System Type (in Acxordance W�ih `T'ab�e Va): TWS S�YSTF�A MAS • BE�i 1NSTALL E� IAi Ga�ilPt.l�►AIC�- .1NITH APPUGAF3IJE. NORTH CAROi.YNA CEAIEiZAL..STATUTES, -RUt.�� L� SEi11iAGE''FREA.TME�IT AIVD I?fS�L, . AND ALL GaNDC[1t3NS ..OF ;: TI3�. IifdPRC3Y�11F�T� P�ffi�1T AND. -i'.aNS'fRi�C'�[�[al ' .A� - -noN� � � . . . _ �` � J � � , � � �� .� - -� . .. � . � -a.,�� s� �� . . - � . - . , ..-- . . . °� . . p�,. �lt�e. _ ��- �i`�9� I� +yl � �r . ' � - � � �� ,� �s � 5� h� �s �-��( �- ril��„ � �� Ma-j�✓ � � � a �oQ ��s �� -�c� • ��. � �� 1 a _ ��°/ i qo' �c��. r�r. a��z��c2 '}. � . S�C �'�Ht il�..��'iit�i�l ��iJS'i' ('�'�s A �- � . . � . T� Nia,p � 27 P^�f �- �f� - . Systes�t Type (T �a) . o,am��licarr� � S� - �J�, , ��,,�5 Addr�ss�L.oca�ion � S�� ' � ` . - • � � •f - . 0 X Application Date: c� t Amount Paid: � Q , D Receipt #: $' �} �t 9 4 9 C�ed; ❑ Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 d) Mobile Home Replacement or Building Addition $150.00 (if site visit required) 0 Well Permit (New/Replacement/Repair) $300.00/$200.00/$75.00 ��+ f �� Tax Map:-;�� ,.,,.,._ ' � � �� Parcel#: lE�,.'nnv nn-�cava.v.xa�3n.d.m.11 7F-jla,.s,1L�::La. tion for Services Services ❑ Construction Authorization (Fee is dependent on the type of ❑ Permit Revision $75.00 ❑ Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 7C 1) Applicant Information• Name: ` C/�02 /�'l0/�$it�il� Address:/o? O pLLS�Is /C /� O�C�3o/ZD �7s ? 2) Name and address of current owner (if different than applicant): Name: Address: 3) Property Description: Lot Size: �� Subdivision: �� Address andlor directions to Property: /�? U o L Phone (home): 33 �" � � �O� (work/cell): 3 3 — � 3 — �� 7 �i Phone: r/C N'<�ot #: ❑ yes [�" o Does the site contain any jurisdictional wetlands? � yes �o Does the site contain any existing wastewater systems? ❑ yes no Is any wastewater going to be generated on the site other than domestic sewage? ❑ yes P1no Is the site subject to approval by any other public agency? ❑ yes �no Are there any easements or right of ways on this property? (if `yes' is checked, please provide supporting documentation) 4) Proposed Use and Type of Structure: ❑Residential � ❑ I�Iew Single Family Residence Maximum number of bedrooms: C�Expansion of Existing System tf expansion: Current number of bedrooms: � ❑ Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures? ❑ yes ❑ no ❑Non-Residential Type of business: Maacimum number of employees: Total Square footage of Building: Maximum number of seats: 5) Water Supply: ❑ New well ❑�'Existing Well ❑ Community Well ❑ Public Water ❑ Spring Are there any existing wells, springs, or existing waterlines on this properiy? ❑ yes ❑ no 6) If applying for `Authorization to Construct', please indicate preferred system type(s): ❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative � Other ❑ Any I certify that the information provided above is complete and correct. I also understand that if the information provided is inaccurate, or if the site is subsequently altered, or the intended zrse changes, all permits and approvals shall be invalid. 7 _ / U �a- /� Signature (Owner/ Legal Representative*) Date * Supporting documentation required. • Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat. • A completed `Lot Preparation' form must accompany any application requiring a site evaluation. (10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) ��.s� ��..� �� C��: ��.Il IL�'L��.71�1� Applicant: }i�.c�00.. � Address/L.ocation: I �-o Tax Map: a`l Parcel: a4$ Subdivision 1�'aw.�� M �act�s Phase/Section/Lot # � improvement Permit Perinit Valid for: Five Years � Non-expiring ___ Type of Facility: �-�o�a� 4�s�. New Addition �C Number of: Bedrooms / Occupants$!�/ Employees / Seats: Proposed Wastewater System: !�P C��i.��ara��t�- Proposed Repair: �iiMp A�reo c.as�d �v�"�� Permit Conditions: �o�.�.... Q.v.�► � Water Supply: vr��. Wi.ls... Projected Daily Flow: 8a gallons/day Type: TIS � Type: '�.�6 sc�. Authorized State Agent: -` _ Date: (X) Uwner or Legal Representative: Date: The issuance of this permit by the Health Department does not guarantee the issuance of other required permits. It is the responsibility of the applicandproperty owner te insure that all Person County Planning and Zoning and Building Inspections requirements are met. Thes Improvernent Permit is subject to revocation if the site plav, plat or the intended use changes. The Improvement is not affected by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina `Laws a�rrl Rules for S�waFe Treatment and Disnnsul Svstems'(15A NCAC 18A J9U0). Neither Persan County nor th� Environmental Health Specialist warrants tl�at the seFti� syst�m v��ill continae to fu�ction satisfactoriiy in the fature, o; that the water supply will rerrain patable AuthoriEation to Construct Wastewater System See site plan and r�dditional attaciiments (_). x Proposed Wastewater System: QU!►�t� �'�o•��t�kt- (*)Tyge 'I'�iii Design rlow y8� __ ga1./day Ne�.�� Kepair _ Expansicn � Soil LTAR: �- 35 gal.; cay/ft2 Type of Facility: 5�►�blft FAr►��>t OU+�-•J►b �"3'` � f'►31P`� Basement: _ Yes � No (*) Sysle�r� Types Illb, IIIbg, IY; end V, require periodic system inspections �y the Perso� Count�J Health De�artment. �,�Vastewater System Requirements Tank Size: Septic Tank �S�a� gai. I)raintield: Total Area ''�d� sq. ft. Trencli Width � ft. Pump Tank '�sz, t,gal. Total Length Iba ft. Min.Soil Cover �_ in. Grease Trap '— gal. Max.1'rench Depth 1$ in. Min.Tren�h Separation 9 ft. Distribution: Distribution Box / Serial Distribution / Pressure 1�tanifold i'L Specifications: �_'��r�s�oi� ►��16 '�.a��.wo ; Cf�ul. w I A-t�►`l 4�-stivt�S Authorized State Ag�nt: Issue Date: 10 Permit Expiration {�r�P - Tlie system permitted is: Conventional _,�__ ;Accepted / Aiternative / Innovative . I accept the conditions and specifications of this permit. � �� l-� �� .� (Xj Owner or Legal Representative: % Date: � Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12) \��.�� . •� ' - v v� J. V Y 1�. ` IEaa.�v�a.a-�m�aaa�aa�m.0 IH[�e.�.11•E�a Owner: c+0� h'1v1�,Sf}� Tax Map: Aa`l Parcel #: dy� Date: �a '1 13 N1ac�\'G��"G O ,�� ► �a,a d=� I.ine Tap '�ap (Sch) T'ap �opv I�ine L�ngth ]E�oe� / ffoot # i)iameter(va) ( m) �:. (ft) 1 `/3� �O S J � O r'0`� 7 2 $� '• �5.5 ��o . 4'1 �i 3 `�v `l•1 B� ��o�R 4 40 7.i 8�0 , ogg 5 �a h-i qo . o�q 6 4�0 �. 90 . o�l 7 � �} y 4 'XC' � ,5 -,&�t ►�.a .,�e�'Y • c'1g S =�r �' ..� ysat� 9 �.0 � `� • � , �lo�i O ` S1. -� Z v ��rc, ��fl ft of line x 65 gal, per 100 ft= 4ibao. `1i1�c►a ; 100 =`��b gal 75% x`��v gal = 31�-- gal per dose � gal per minute (gpm) = I+'low Itat� Friction �ead Loss: �•�1�-- ft per 100 ft of supply line x�4 ft of snpply. line =1G0 =�• i' �C► ft • i�—ft x 1.2 =�•�b3 ft of friction head �. Manifoldl Size: �_" �orc� Main Size: �- " PVC Total Dynaa�ic �ead =�o ft of Elevation head +�- ft of Pressure head +�.ii�3ft of Fricdon Head = 18. b� TDH 5� . Ptunp Requi�ement: -� GPM @ ��. ft of H ad fl?rawdawn: ��- gat per dose : 21 gal per inch = l� • q inch dra.wdown per dose . , . r :.r �:� , :, , ,� � �,� � _ ., - . ' �� - � i� ��t0 , ,. i ._ " `;'„' : I I I I �� [c�)l��O�7 7 1�1 1�) �) 1�/ ii�i*ii�"iiiiii�ti.ii�i*iii��.�i�i �►�*aa.+*��ata�i��i*��f:�a+�*�� _ :.._. ..... ' I I r • :.� ..._ : a :� : : v: 1,,, ..,....._ 9ma� I ' s �5 �, a�o�J 'Lc�.�-jt-. l`�d �� LI�� =� dR. �Awvr�u.�c . . . • - . " �'i0w E! TaP Si�e 1Lfrueriai FTow GP3�1 ?.4'• Sc3ied 80 .i.� ;; " Sch¢d 10 i.l s� " Scl:ed 80 10,1 q, •' �cl:ed ?�1 1 �..i c•��`1��, � }�S �d=- ,b� �J �� °�-� ��4�'�'`�'\l�� a�. v ., .'. •-� . � . r. , ' �' aazy }eo13 . al4ee°uzag-i c}eot,; .� i. ; � san jy� }ra� _ adzd �AdOtrH�S ��Z _'� �^^"j ua�;nqu}ssQ oy;at}np . • + �?'I }nauJ luauza� pue�uod �Iddns K}.LYl Paii?3 �u�uadp ' , _ • n}ss� - - 3�J a;azazo� pur�}zod� y _ . _ .!%�J�" t : ' . . . ua�}e:eda$ „4 sassg a}azouo� x�z �na uozz�� o�! �r�� • . • ,. . • , . . ' � • ' • . ' '. • '. • '�' �. , �[�as saoosE<��}st��Yy�j ':• _ a�az,uo�.tr Ku�e,La}azauo�;se�azd .%; :; dtund •� .�30 dtiuc�- tanaZ mo7 • (lL'H dA) � �� ; � • eI�H �sza ��?1 � •, " x�oZ zodrA�. . up dius� - jana'I �H ' �ua�}ezrdaS .9) ' T�aZ �IV za}shA �H ' ado� �IEA . ua�dH�• x�� ' �II�H �D� }nQzJ }uauxa� puej�zod saiy I ajoj.j uo�dzg s}uy t�3t.AA FaIT?,i =uivadp •'' �o� dSZ � - � ' � � .: • . �.'. , �i•� ; . '� � � .... � . _ - . ' •sawo� csa��y � •. liOttl jl . � • a • • � ��e ��4� p��i � , . . T �� t��}�� uz�nsmnYI wtiZ � d }?�°� �'i.L30'�3 �}ogjeas }� adid �Ad Otr H�S ��tr xue.L n�das uzoz� }ajuI '•. . zano� „g UOT}YIY as r .T.t za}e� Pa'iS °.L PadOIS � }sod pa}eazy amstazd ��b X ��tr �� T�d i°z�uo� xatdunS Xtr Vi^I3H 0 Application Date: _ l�) �-f' �� ) f �11d�� lY�. V Tax Map: AmountPaid: _-�� • �.�� Parcel#s Receipt #: IE�mdna-anTM*,•*�„�o�.��o..11 ]Hims..11d,lla. for Services Services Re uested ❑ Improvement Permit (Site Evaluation) 0 Construction Authorization $200.00/$300.00 (if> 600 d Fee is de endent on the e of s stem ermitted) ❑ Mobile Home Replacement or Building Addition ❑ Permit Revision $ I50.00 if site visit re uired) $75.00 ❑ Well Permit (New/Replacement/Repair) 0 Repair of Existing Septic System $300.00/$200.00/$75.00 Application: No Charge/ CA $150.00 or $300.00 1) Applicant ormation�• " Name: / �'Ui� � �U'UGJ Phone (home): Address: (oa� FCtr�► G�-1 %�,� (work/cell): 3?�-SJa3 - 7o?v?`� 2) Name and address of current owner (if different than applicant): Name: �Ec��r� �ion�S�� Phone: 336 'S% %-� � % Address: � �.o (l,�:.t,�,� < <rz.rc�� .7/t.. 3) Property Description: Lot Size: Subdivision: Address and/or directions to Property: Lot #: ❑ yes no Does the site contain any jurisdictional wetlands? ❑ yes no Does the site contain any existing wastewater systems? ❑ yes no Is any wastewater going to be generated on the site other than domestic sewage? ❑ yes no Is the site subject to approva( by any other public agency? ❑ yes no Are there any easements or right of ways on this property? (if `yes' is checked, please provide supporting documentation) 4) Proposed Use and Type of Structure: esidential ❑ New Single Family Residence Maximum number of bedrooms: ❑ Expansion of Existing System If expansion: Current number of bedrooms: 0 Repair to Malfunctioning System Will there be a basement? 0 yes ❑ no With plumbing fixtures? ❑ yes ❑ no ❑Non-Residential Type of business: Maximum number of employees: Total Square footage of Building: Maximum number of seats: 5) Water Supply.: ❑ New well �Existing Well ❑ Community Wel( ❑ Public Water ❑ Spring Are there any existing wells, springs, or existing waterlines on this property? 0 yes ❑ no 6) If applying for `Authorization to Construct', please indicate preferred system type(s): ❑ Conventional ❑ Accepted ❑ Innovative O Alternative ❑ Other ❑ Any I cert� that the information provided above is complete and correct. I also understand that if the information provided is ' acc rate, or if e site is subsequently altered, or the intended use changes, all permits and approv ls sh 11 be invalid. � . � �� ,� � y Signature (Owner/ Legal Representative*) Date * Supporting documentation required. Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat. A completed `Lot Preparation' form must accompany any application requiring a site evaluation. (10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) . `, �� ; � i' , � � �° � ( � � �� ; 1 .� � I� :� � � � : , ..� ;i . D 4.r .a�` � `�—�''� � �� c�' �� ' ��.- � �',��..Z.�-�i��_rz�.n,e�.�.�1:<�.�. �� +��<m.�l�:ll� �a��d��3 ��m��/ lY��bn�� a�� fl��a��u�5 Tax Nlap #: Aan Parcel#: a'i$ Address: I�O RAw..ab C�c.-�x '1�R�• Approval Requested for: Mobile Home Fceplacement X Building Addition Applicant Name: '�Ev rt�� 0� aQ�� Address: t� a� fvt r c,u��rm� RO Phone#'s: 33b-s'o3- �a�°t Permit Located: x Yes Tlo Installation Date: IO � 13 Design flow: �80 (gpd) Curreat Cantract with Certified Operator on file (if required): �_ . Water Supply: 7� Well �'ublic or Community Wast�water system shows no visual evidence of failure on: y/!Y/1 K (date) (Applicant's signature if site visit is not required) �c (, � Comments: �+'�''i c�ovEi� 1-o�(z. 3� � xa-b� �� rs��'t�� r��/��at ��pu-��s� �1� R�c.�L A. Sr� Environmental Health Speciaiist �} 1`� la Date PPrson Co�n�� Environme:�tai ;� ealth; 3�5 �. ylorQan St., Suite C, RoYboro, NC 2 i�; 3 Fhcne:.��b-597-??9C/ra;:: ��-�9"-78f�� -��:.��.�ersoncoun�tv.i,e� ��, j 1� ��4�� _ � � �Tl V ��T � '33N7L'L. OIC1a33�07C31.��.JL �10�.'��YA. SITE PI.AN Name ��Q" M�a� Tax Map # `L Pazcd # a�'� Subdivision 6 M • �k1�1'►S Secrion/Lot# (�L�►cx. St� 1 ` .Suthorized State Agent a e System components tepresent �ppm�mate contours only. The coatraaormusttlag t6e system paror ro beginning the iastall�tion ro insure rhat pmpergrade is maintained. • � it4f 6 .a� f '�R� U� ft W o�C.O -``-`�--�. Paoer� L��£ I�T ��'j :2 T �� hf , ��, 165'S5 '[d8fi 5� :� � � oJEw u�. — — — — _ £x�s�.►1�0 �awtiE � 1 : 64 Feaf � L,..� ��, sf ��.� �� I��.�a-��.Il IE-� ��,IL�I� Applicant: �r c..�vtL, M � Location: lao t�u.tiat Taz Map /la`� Parcel # a`i t� Subdivision �ab`` 1'�' t-��5 Phase/Section/Lot # # of Bedrooms � O eration Perrnii � 3-�� System Type (From Table Va): �'i i� �'�6 Type V& VI Expiration Date: Product (IIIg): (�av'c.L �" �-Z �°� Type V& VI Renewal Date: This system has been installed in compliance with applicable North Carolina General Statutes, Rules for Sewage Treatment and Disposal, and all conditions of the Improvement Permit and Construction Authorization. 1J�ct�. A. 5hc-�l (Authorized Agent) C _ Ca�,►� (Licensed Contractor) t'O d5 l�y (Date t� �s i3 � , �Da ) �� qo �� L�6�-�O — �'x�s,�r�, t� ��. �F��.i � _ .... �,oa�.t� Av��r1►�r\� �.�Z- ��"'`� r �,� ��- w�- � Scale S PCHD, rev. 12/14/12 Line Length t � bo' �sz-tn1 � ��' -��..,, t, �o' Tax Map: �A�'l Parcel #: 02�8 Septic Tank System Checklist (Type II-I� Notes• ` ' System Type: �iA �co � Pump System Checklist Contracted Certified Operator (Type IV Systems): Notes: � PERSON COUNTY HEALTA DEPARTMENT SiJBSURFACE WASTEWATER SYSTEM MOrTITORING REPORT -1 31 ��} �-b-o� �'��aS��3 71c� fla.`1 ��$ Date of Inspection System Installadon Date Type Tax Map Parcel # lao R,�a.,.,� C��- �R,. Address .�th5�4�i Instructions: C�eck yes or no for appropriate items and explain in spa;,e gr�vided for remarks and comments. If an item is not applicable, indicate by "NA". If an item is not or cannot be evaluated, indicate by "N" and explain. Note that this monitoring form is not totally inclusive for all systems. All maintenance and monitoring items specified in the permit are to be carried out. INSPECTION RESULTS COLLECTION SYSTEM: Evidence of leaks ? Tank risers accessible, free of infiltration and surface water diverted ? Septic tank needs pumping ? Inches of solids: i0 -1� Septic tank filter cleaned ? EFFLUENT DOSING SYSTEM: Requ'ue3 pumps aresent & funcdona! ? High water alarm operating properly 7 Floats, valves, etc. in good condition ? Control panel & components in good condition ? Effluent free of excess solids 7 Inches of solids(pump/dose t ): �-3 Elapsed time readings ? � Counter readings ? Drawdown rate: �`1 YES / NO ❑ � � r/ ■ /' ■ ►�� ■ i/ ►�1 ■ LI ■ DISPOSAL FIELD: Evidence of effluent surfacing 7 ❑ Evidence of effluent ponding in trenches 7❑ Surface water effectively diverted ? � Diversinns/sv�ales pregerly maintained ? [�Q �eget3ti�e cevPr *n�in±�ned ? +� Protected from tr�c/unauthorized uses ? � Distributiau uevices ui good condition ? Field free of settled or low areas ? � / / / / / / / / E� � ■ ■ ■ ■ PRESSURE DISTt'tIBUTION SYSTEM: Turnups/cleanouts/valves/taps intact & accessible ? � � ❑ Pressure head properly adjusted ? � / ❑ COMPLIANCE: Compliant Non-compliant Needs Maintenance f`SiDiiivivfuw Cvivilvir;�dTS: ►:i ■ ► REMARKS • npa — (3�aC�q C,� .L. C t�a�� '�TCS �� . � �-i t'��a �.s ci��S �(�`SE�'t� a► �-X s�" _ ��x.s �- � ti�4. � ��M �i� LL�� — t • �crcS w�6 �1�'"orw� � �r. P�.�i.ri �3�`i� �S�"c(L • • Niftri��o� C�u'�.�� :� (��.�4�i"�S. �P.�t'E�J TO '�}^ou� AL� 'i��t-�� klWO��FWi'�c fI�CU '�.EV v�.�o�c �tt�� rvwwrv� t'��c-o�A c�r�cc4c�waC� : C►.w�*� '��S�a►us�,�t �F��-�. � ,�r� A��- ��s - EHS ��P�►Cat /� . Sh� 1 I I �� ---�, � �� '��'� 7C��nw�«-�b��:��x��,��.� IC��:��l�ll� Date: 0 / « /� Name: QC � Qn `� Address: p i �' • Re: Bacteriological Test Results Dear Well Owner: Tax Map:� Parcel: � �� Your well water was sampled on �/ �� /�, and tested for both total and fecal coliform bacteria. Your water sample test results are 7oted below: � No coliform bacteria tivere detected in the sample. Your well water is safe to use for drinking, cooking, washing dishes, bathing and showering, based on the bacteriological results only. Total coliform bacteria were detected in the sample. Fecal coliform bacteria were detected in the sample. Total coliform bacteria are naturally found in the soil. Fecal colifnrm bacteria are associated with animnal and/or humun waste. The presence of either total or fecal coliform bacteria in well water may indicate that a new or repaired well was not properly disinfected prior to use, or that contaminated groundwater may be entering the well. If coliform bacteria are present in your water sample, tl:e water may not be safe for use. Young children, the elderly, and the individuals with compromised immune systems are especially vulnerable and their physicians should be notifred of the test results. A well that tests positive for total or fecal coliform bacteria should be properlv disinfected and retested prior to resumin� normal use. The well may be disinfected using the enclosed disinfection procedure. A well contractor or plumber can assist you if needed. Once the chlorinated water has been thoroughly flushed out of the system, please contact the Health Department to request a re-sample. For additional information, please feel free to contact Environmental health at 336-597-1790. Our office hours are 8:30 to 5:00, Monday through Friday. Sincerely, � �Y� � Environmental Health Specialist Person County Health Department (rev. 4/20/16) Person County Environmerrtal Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573, Phone: 336-579-1790, Fax 336-597-7808 North Carolina State Laboratory Public Health Environmental Sciences Nlicrobiology Certificate of Analysis Report To: PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET ROXBORO, NC 27573 EIN:566000331 EH COURIER #: 02-33-15 StarLiMS Sample ID: ES071916-0057001 � �� ES Microbiology ID: GPS Number: Sample Description: Comment: Name of System: HECTOR MONSANTO P.O. Box 28047 4312 District Drive Raleigh, NC 27611-8047 htta://slnh.ncaublichealth.com Phone: 919-733-7308 Fax: 919-715-8611 120 ROLLING CREEK DR ROXBORO, NC 27574 Collected: 07/18/2016 13:50 Received: 07/19/2016 08:11 Sample Source: Well Sampling Point: Outside spigot A Sarver Angela Heybroek Well Permit Number: A27-248 Environmental Microbiology - Colilert Profile Method: SM 92236 Test Name: Colilert Analyte Test Result Analyst Date Total Coliform, Colilert Absent Susan Beasley 07/20/2016 E. coli, Colilert Absent Susan Beasley 07/20/2016 Report Date: 07/20/2016 Explanations of Coliform Analysis: Reported By: Susan Beaslev If coliform bacteria are Absent, the water is considered safe for drinking purpose. If coliform bacteria are Present, the water is considered unsafe for drinking purpose. Presence of E. coli (bacteria) generally indicates that the water has been contaminated with fecal material. It must be remembered that a water analysis refers only to the sample received and should not be regarded as a complete report on the water supply. ��.' � ` � 4 j � � ( r � ,.�.�+,� , . F_.` �'-•� k %', 2 E �- r i.r,,� ` l-• �P ,l- �r s ��n s 1,rS �,_�� ' f �� . �� a; t�� i � k; f t € F f �! f�� s L1 L�� f L1 � � � ` � i �,' i � ( � �i �.. � �, ( 4 � f � w--•'. . - - �' G �� ,� �� '^� !�� 4•� f�? f ` �,:f � �� ^Y �^ f l� C (y �t '�i �� ' .'� i ' t^ �+ -,`� � �— � .,..� �� ''�•t �Z �l ��.�' F� E � e P � i ✓ � l � �,1 =�� s•� [ ^� �.,'V r �.: �i For Inorganic Chemical Confamiraants county: SD ✓t Sample ID #: — Reviewer: �� TEST RESULTS AND USE RECOMMENDATIONS 1. �Your rvell ��va±er meets faderal drinlcing water standa: ds for ino�ganic ed�rnica�s. Yaur w�ter cai� be used for drinking, cooking, washing, cleaning, bathing, and showering based on the inarFanic chemical results onlv. You may have oiher water sampiing resuits that are not taken into account in this report. 2. � The following substance(s) exceeded federal drinking water standards or the North Carolina 2L calculated health levels. The North Carolina Division of Public Health recommends that your well water not be used for drinking and cooking, unless you install a water treatment system to r�move the ci:cled substance(s). However, it may be used for washing, cleaning, bathing and showering based on the inoreanic chemical results onlv. 3. 0 a. Sodium levels exceed the U.S. Env�ronmental Protection Agency's�(USEPA) health Advisory level for sodium of 20 mg/1. The North Carolina Division of Public Health recommends that only individuals on no or low sodium restricted diets not use this water for drinking or cooking. It may be used for washing, cleaning, bathing, and showering base� en the inorQanic chemical results onlv. ❑ b. Levels over 30 mg/1 may pose aesthetic problems such as bad taste, odor, staining of porcelain, etc. 4. 0 Re-sampling is reFommendel in months. 5. [J Re-sample for lead and /or copper. Take a first draw, 5 minute, and 15 minute sample inside the house (preferably the kitchen) and if possible a first draw, 5 minute and a 15 minute sample at the well head to determine the source of the lead and/or copper. 6. ❑ The fol(owing substance(s) exceeded federal drinking water standards. Your water can be used for drinking, cooking, washing, cleaning, bathing, and showering based on the inorganic chemica! results �nlv, but aesthet�c pro�leMs such as bad taste, odor, staining of porcelain, etc. may occur. You may t�vant to install a househoId water treahnent system to address aesthetic problems. Barium � Cadmium � Chromium � Fluoride � Iron Man�anese Selenium Silver pH Zinc For more informatton regarding your wel! water results, pfease call the North Carolina Division of Public Health at 919-707-5900. 0 North Carolina State Laboratory of Public Health 3012 D�st�ct�D �e Environmental Sciences Raleigh, NC 27611-8047 htto://slph.ncpublichealth.com Inorganic Chemistry Phone: 919-733-7308 Fax: 919-715-8611 Certificate of Analysis Report To: ADAM C. SARVER Name of System: PERSON CO ENVIRONMENTAL HEALTH HECTOR MONSANTO 325 S MORGAN STREET 120 ROLLING CREEK DR ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574 EIN: 566000331 EH StarLiMS ID: ES071916-0041001 Date Collected: 07/18/16 Time Collected: 1:50 PM Date Received: 07/19/16 Collected By: A Sarver Sample Type: Raw Sampling Point: Outside spigot Well Permit #: A27-248 Sample Source: Well Temp. at Receipt: 5.0 GPS #: Sample Description: Comment: New Well 1(Profile) Analyte Result Allowable Limit Unit Qualifier(s) Arsenic < 0 005 0.010 mg/L Barium < 0 1 2.00 mg/L Cadmium < 0.001 0.005 mg/L Calcium Chloride Chromium Copper Fluoride I ron Lead 33 7.70 < 0.01 < 0.05 < 0.20 < 0.10 < 0.00: 1.3 4.00 0.30 m m Manganese 0 045 0.05 mg/L Mercury < 0 0005 0.002 mg/L Nitrate < 1.00 10.00 mg/L Nitrite pH Selenium Silver Sodium Sulfate Total Alkalinity Total Hardness < 0.1 7.6 < 0.005 < 0.05 9.10 17.00 102 � � �+ � � 250 Zinc 0.21 5.00 Report Date:08/01/2016 Page 1 of 1 Reported By: Cin�fy Price ��.�� .� �� ----- � � ��-�� .� �� 5��.�� s�� _ �� P #: a � �� # � �o�� P�;.�� -�or►�c, 1-�c�.d� c.�.urtcrr.s Su�divisioaa: �� `nti_� m5- -- Ser.saon: �� Locati�n: T'�e of Wat�s� 5��: � Individual Communitp Public. s s !f ��s�t�t��a��• � . Site. Approved G�outti�ng A ved by �- s"�� ell Log . Well T A.ir Vent _ � Hose Bib Concrete Slab �_� - i, r , ;� . 1 , � . _ u �� '� ' .� F : �, ♦ . .��. �.i: • '�I,� �� -,�' ' �G2t �t4�C$CS� SBt� S��C�1� Wells must be 10 feet from propertp ]iaes. Wells must be 100 feet from septic systems. � Wells must be at least 25 feet from anp bwlding foundation. Other condi�ions: ��C t-D i..) c. [ I j 00' FrD m S�A�1��- �' l t�A� �rn �. C�"�-iC /S P �in9 , � 0 PC�ID, rev. 09/07/Oi BarnetYe Well Drilling Inc 336 598 9275 03/25104 01:20P P.001 r . � s.� � �� D�QDOar OD � � a�y .`��`'- . � [�o ..�� ,��J� / r�_ `~'` � � �T1�T�C'� ��,._.,�,� �j ry /7�1 �uavn.x-�Ya�� ..�.rn.� • ��r�L�.tE:�a L"R�{l9ld 0 � ° 3 "J�'�~(/ T Owner: C�rout Y.og . . Tax Ntap �� Parcel # �� 1 _ _. . . . • __ �- • _ - � I.Ot #� 'Well Construction Distancc From nearest Property Line (Minimum 10 feet) Distance from Septic System (Minimum 60 feet) Total Depth: ,� �( O ft Yield: u' GPM Statio Water Level: _�S ft VV1tCi' Beaiing 70nes: Depth�,�, ft�ft it ft •4f' �i n ts � . / � CASit�g: pcpth: From �_ to �/2 ft. Diatx►cter: �f in Type: Galvanized Steel ��_ �eight abovc Ground: in Wei�)nt: ��„ �' - �7rive Shoe: _�Yes No . Any problenns enaountered while setfiing casing? Ycs ��]'o if `j�es" give reasom Grput: � Ncat: SandlCement c% Concrete GxavellCement . Annular Space Width inches Water in AimuIar Space Yes No Method of Crrout: �unped Pressure Pot►red �� D�pth _� to �_ Ft Matcri4ils YTsec�: �To. Ba�s Portland cement `'� W�ight of 1�ag �, Pounds If mixture (satld gravel, cu ings) — Ratio to ID plates: �es _ No 4 x 4 slab _�1'es _ Na Liner: I7cpt,h; Date Installed: Crrout: Znstalled by: brilling Log Y,ocation brawing I htroby cextify that the ahove information is coircct and that this '�vcll was cons�ucted in accordance with regulations set fortt: hy tho Ptrson County Health Departinent. � f� Si�uaturc of Coutractor lD # _1�� DAtc _,� ��Q � Pump Ynstallment Pump Installation Contractor: � h� ��-�� lE State Regist�ation Number: .�C1 L�l-� pump Depth: /2C� ft Sta.tic Water Level: , x.� ft Puzx�p 11�al.co & Model: Q,.sl ...ti�`ck.�_ �- �S �-�.��. Pump Size and Rating. ��_.,....,.,,hP ?'�_ SPm i hereby certify that tttis pump was installed and the wcll head completed according to the Person Cotmty Wtll Ruies in eflect on this date and that a copy of this record has been vidcd to the well owner. . 1'umo Ynstaller Sf�natare �� . 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